The KAAACI/KDA Evidence-Based Practice Guidelines for Chronic Spontaneous Urticaria in Korean Adults and Children: Part 2. Management of H1-Antihistamine-Refractory Chronic Urticaria

Predicting responses to omalizumab in antihistamine-refractory chronic urticaria: A real-world longitudinal study

Background

Treating chronic urticaria (CU) that is unresponsive to H1-antihistamines (H1AHs) is challenging, and the real-world effectiveness of omalizumab remains unclear.

Objective

Our aim was to evaluate the real-world effectiveness of omalizumab, optimal response assessment timing, and predictive factors.

Methods

Initially, 5535 patients with CU who were receiving at least 20 mg of loratadine daily for at least 6 months (January 2007-August 2021) were screened. Ultimately, 386 patients who had been receiving omalizumab add-on treatment for >6 months were followed-up for more than 2 years. Predictors of treatment response to omalizumab add-on therapy for patients with antihistamine-refractory CU were identified by using a generalized linear model.

Results

In our retrospective cohort, omalizumab treatment showed cumulative response rates of 55.2% at 3 months, 71.0% at 6 months, and 81.4% at 9 months for patients with H1AH-refractory CU. Analysis of longitudinal responses to omalizumab treatment revealed 3 distinct clusters: favorable (cluster 1 [n = 158]), intermediate (cluster 2 [n =1 43]), and poor responses (cluster 3 [n = 85]). Subjects were categorized on the basis of whether they had achieved a complete response within 3 months; 213 early responders, 117 late responders, and 56 nonresponders were identified. The initial dose of omalizumab differed significantly among the 3 clusters. Low total IgE level (<40 kU/L) predicted nonresponse (odds ratio [OR] = 3.10 [P = .018]). Early responders were associated with a higher initial omalizumab dose (≥300 mg) (OR = 2.07 [P = .016]), higher basophil counts (OR = 2.0 [P = .014]), total IgE levels exceeding 798 kU/L (OR = 0.37 [P = .047]), and lower platelet-to-lymphocyte ratio (OR = 0.50 [P = .050]).

Conclusion

Real-world data reveal 3 distinct clusters for response to omalizumab treatment; confirm low serum total IgE level (<40 kU/L) as a predictor of nonresponse; and identify potential biomarkers, including IgE level, basophil count, and PLR, for early responders.

Systematic Review and Critical Appraisal of Urticaria Clinical Practice Guidelines: A Global Guidelines in Dermatology Mapping Project (GUIDEMAP)

BACKGROUND

Management of urticaria can be optimized with clinical practice guidelines (CPGs). However, the quality of recent urticaria CPGs remains unclear.

OBJECTIVE

To identify and appraise urticaria CPGs worldwide published in the last 5 years.

METHODS

A search for relevant urticaria CPGs was conducted between January 1, 2017, and May 31, 2022, using the following databases: MEDLINE, Embase, National Institute for Health and Care Excellence (NICE) Evidence Search, Guidelines International Network, ECRI Guidelines Trust, Australian Clinical Practice Guidelines, Trip Medical Database, and DynaMed. The included CPGs were critically appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, Lenzer et al's red flags, and the Institute of Medicine (IOM) criteria of trustworthiness.

RESULTS

We included 21 urticaria CPGs. Most guidelines reviewed treatment recommendations of chronic spontaneous urticaria. The majority of guidelines were from European and Asian countries with high and high-middle sociodemographic index, written in English, and openly accessible. Seventeen guidelines (81%) had at least 1 AGREE II domain rated poor quality. Applicability, rigor of development, and stakeholder involvement were the 3 AGREE II domains that scored the lowest across guidelines. Appraisal with Lenzer et al's red flags showed that 18 guidelines (86%) raised at least 1 red flag indicating potential bias. The top 3 domains raising red flags were: no inclusion of nonphysician experts/patient representative/community stakeholders, no or limited involvement of a methodologist in the evaluation of evidence, and lack of external review. Based on IOM's criteria of trustworthiness, 20 guidelines (95%) had 1 or more criteria that did not meet best practice standards. The 3 domains with the highest number of best practice standards not met were updating procedures, rating strength of recommendations, and external review. Guidelines scored highest for the AGREE II domains of defining scope and purpose and clarity of presentation, and had the most fully met IOM's best practice standard for articulation of recommendations. However, only 1 urticaria CPG by NICE was identified as rigorously developed across all 3 appraisal tools.

CONCLUSIONS

The quality of urticaria CPGs in the last 5 years varied widely. Only the NICE urticaria guideline consistently demonstrated excellent quality, high trustworthiness, and low risk of bias. Use of a rigorous framework to rate certainty of evidence and grade strength of recommendation, involvement of methodologists, stakeholder engagement with external review, and clear guidance for updating can help improve the quality of future CPGs.

Clinical Response to Low-dose Omalizumab Treatment in Chronic Spontaneous Urticaria: A Retrospective Study of 179 Patients

Omalizumab is effective in chronic spontaneous urticaria unresponsive to antihistamines. Of the licensed dosing schedules, Korean patients prefer a low dose, of 150 mg/month, for financial reasons. However, real-world experiences of low-dose omalizumab consumption have not been reported. The aim of this retrospective study was to assess the treatment outcomes and long-term clinical course of patients with chronic spontaneous urticaria who were treated with low-dose omalizumab. The study included 179 patients aged ≥ 20 years who were treated with omalizumab 150 mg/month for ≥ 12 weeks. Baseline disease activity was mild, moderate, and severe in 54.7%, 35.2%, and 10.1% of patients, respectively. A complete response was observed in 133 patients at 12 weeks, among whom 88 patients showed early responses within 4 weeks. Overall, 158 patients finally achieved a complete response. Multivariate analyses revealed that baseline disease activity is more likely to be mild in patients who experience early and final complete responses. The absence of atopic comorbidities correlated with an early response. Smoking was associated with a final complete response. This study shows that low-dose omalizumab provides favourable treatment outcomes in antihistamine-refractory chronic spontaneous urticaria. Disease severity, atopic comorbidity, and smoking may be predictive factors for studying the response to omalizumab.

Efficacy of Second-Line Treatments in Chronic Urticaria Refractory to Standard Dose Antihistamines

PURPOSE

The prevalence of chronic urticaria (CU) is increasing worldwide, and it imposes a major burden on patients. Few studies have evaluated the efficacy of second-line treatments of CU, particularly for patients being considered for costly third-line treatments such as omalizumab. We compared the efficacy and safety of second-line treatments of CU refractory to standard doses of nonsedating H₁-antihistamines (nsAHs).

METHODS

This 4-week, prospective, randomized, open-label trial divided patients into 4 treatment groups: 4-fold updosing of nsAHs, multiple combination of 4 nsAHs, switching to other nsAHs, and adjunctive H₂-receptor antagonist. The clinical outcomes included urticaria control status, symptoms, and rescue medication use.

RESULTS

This study included 109 patients. After 4 weeks of second-line treatment, urticaria was well-controlled, partly controlled, and uncontrolled in 43.1%, 36.7%, and 20.2% of patients, respectively. Complete control of CU was achieved in 20.4% of patients. Among the patients with high-dose nsAHs, the proportion with well-controlled status was higher compared to the patients who received standard doses (51.9% vs. 34.5%, P = 0.031). No significant difference was observed in the proportion of well-controlled cases between the updosing and combination treatment groups (57.7% vs. 46.4%, P = 0.616). However, increasing the dose of nsAHs 4-fold was associated with a higher rate of complete symptom control compared to multiple combination treatment with 4 nsAHs (40.0% vs. 10.7%, P = 0.030). Logistic regression analysis confirmed the higher efficacy of updosing of nsAHs for complete control of CU compared to the other treatment strategies (odds ratio, 0.180; P = 0.020).

CONCLUSIONS

In patients with CU refractory to standard doses of nsAHs, both updosing of nsAHs 4-fold and multiple combination treatment with 4 nsAHs increased the rate of well-controlled cases without causing significant adverse effects. Updosing of nsAHs is more effective for complete CU control than combination treatment.

Existing and Investigational Medications for Refractory Chronic Spontaneous Urticaria: Safety, Adverse Effects, and Monitoring

Treatment of chronic spontaneous urticaria (CSU) is responsive to H1 antihistamines administered up to four times the recommended US Food and Drug Administration dose in approximately 50% of patients. However, when patients do not respond to these first-line agents, evidence-based guidelines using Grading of Recommendations, Assessment, Development, and Evaluations methodology have provided direction for second- and third-line treatments that can effectively treat patients with CSU. Some patients remain refractory to these advanced treatments; therefore, alternative treatments with a lower certainty of evidence may be necessary. Regardless of the therapies used to treat CSU patients, it is essential for clinicians to be knowledgeable about the mechanism of action, efficacy, and safety and monitoring recommendations of the treatments prescribed. This review provides a comprehensive review of the adverse effects and monitoring recommendations for agents in use for CSU treatment as well as those currently undergoing investigation for CSU treatment.

Diagnosis and Management of Urticaria in Indian Settings: Skin Allergy Research Society's Guideline-2022

Urticaria is a common skin disorder. Chronic urticaria, i.e., the presence of symptoms for more than six weeks, is associated with a significant adverse impact on sleep, performance, quality of life, and financial status of the patients. Although several treatment options are available, the condition can be challenging to treat for many clinicians. Several updates have been published on the subject of urticaria and its management since the publication of an updated consensus statement in 2018 by Indian experts. The objective of this consensus statement is to summarize the updates and provide concise information, including classification, diagnosis, and management of urticaria. Understanding and elimination of the underlying eliciting trigger are essential in all possible cases. The goal of pharmacological treatment is to provide symptomatic relief. Second-generation nonsedating H1 antihistamine continue to be recommended as the first-line treatment, the dose of which can be increased up to four times in patients not responding satisfactorily, in the second step. The role of omalizumab, cyclosporine, H2 antihistamines, and other options is also discussed.

The burden of symptomatic patients with chronic spontaneous urticaria: a real-world study in Korea

BACKGROUND/AIMS

Chronic spontaneous urticaria (CSU) poses a considerable burden both on the quality of life (QoL) of individual patients and on healthcare systems. Real‑world data evaluating the disease burden of CSU are limited in this country. This study evaluated the disease burden and healthcare resource utilization (HRU) among symptomatic CSU patients.

METHODS

This multicenter, noninterventional, retrospective, and cross-sectional study assessed CSU patients symptomatic for more than 6 months despite step-wise H1-antihistamine medications. Primary outcomes included Urticaria Activity Score over 7 days (UAS7) and Chronic Urticaria QoL scale (CU-QoL). Secondary outcomes included EuroQol 5-Dimension 5-Level (EQ-5D-5L), Dermatology Life Quality Index (DLQI), association of disease activity with QoL, medications used for the past 6 months, and HRU.

RESULTS

Five hundred patients with CSU were enrolled. Mean disease duration was 3.7 years. Based on UAS7, 22.2% of patients were in well-controlled status and 31.2%, 28.4%, and 18.2% of them had mild, moderate, and severe disease, respectively. Mean CU-QoL and DLQI scores were 57.5 ± 29.7 and 10.2 ± 7.6, respectively, while the EQ-5D-5L utility score was 0.8 ± 0.2. H1-antihistamines were prescribed to 95% of patients, while omalizumab was prescribed to 33% of patients. Most patients (98%) had outpatient visits in the past 6 months. Negative correlations were noted between UAS7 and CU-QoL, EQ-5D-5L, EQ-5D-5L visual analog scale scores, but a positive correlation was noted with DLQI score (p < 0.001 for all). The number of outpatient department visits increased with disease activity (p = 0.001).

CONCLUSION

CSU affects QoL, leading to increased HRU, particularly in patients with severe disease.

Taiwanese dermatological association consensus for the definition, classification, diagnosis, and management of urticaria: A 2021 update

Urticaria is a prevalent disease with substantial physical, psychological, and economic impacts. With the advent of understandings of the disease and the emerging evidence of treatments, the international guidelines for treating urticaria have been updated in recent years. In order to update the 2014 edition of the Taiwanese Dermatological Association (TDA) consensus of urticaria, a total of 17 dermatologists with extensive experience in urticaria management were invited to and attended the TDA consensus meetings. All the specific aspects of the content were approved by at least 75% of the experts in attendance. Comparing to the former edition, several substantial modifications were made. For diagnosis, D-dimer was added as the recommended routine test in patients with chronic spontaneous urticaria. For pharmacological management, treatment suggestions were simplified. The approved-dosed, the up-dosed second-generation antihistamines, omalizumab, and cyclosporine were listed as the first-line to the fourth-line treatment, respectively. In addition, the management for patients of special considerations, such as the elderly, children, and pregnant women, were all discussed and mentioned in the consensus. We hope the updated TDA consensus can serve as a reference for all physicians and can help the physicians providing up-to-dated managements for these patients.

Increased serum free IgE levels in patients with chronic spontaneous urticaria (CSU)☆

Background

IgE bound on the surface of mast cells contributes to the pathogenesis of chronic spontaneous urticaria (CSU). Atopy is a predisposing factor for CSU, where omalizumab is a widely used monoclonal antibody to control urticaria symptoms via capturing serum free IgE. However, the role of serum free IgE is not clarified in CSU. The present study evaluated the clinical relevance of serum free IgE in patients with CSU.

Methods

Eighty-eight patients with CSU and 76 healthy controls (HCs) were enrolled in this study. Serum total and Dermatophagoides pteronyssinus (Der p)-specific IgE levels were measured by ImmunoCAPs. The serum free IgE levels were measured by ELISA using a novel IgE_TRAP, and their associations with clinical parameters, including urticaria activity score (UAS), were evaluated. Changes in serum free and total IgE levels after omalizumab treatment were observed in 23 CSU patients in comparison between responders (≥50% reduction in UAS) and non-responders (<50% reduction).

Results

Significantly higher serum free/total IgE levels were noted in CSU patients than in HCs with a positive correlation between the 2 values (rho = 0.87, P < 0.001). Among CSU patients, atopics had significantly higher serum free IgE levels than non-atopics, while no associations were noted with UAS, urticaria duration, or the results of serum ANA or autologous serum skin tests. In addition, there were no significant changes in serum free IgE levels during 12 months of omalizumab treatment. No significant differences were noted in serum free/total IgE levels or clinical parameters between responders and non-responders, while responders have higher serum Der p-specific IgE level and its ratio to serum free/total IgE level than non-responders (P < 0.05, respectively).

Conclusions

These findings suggest that increased serum free IgE may be involved in the development of CSU by activating mast cells, especially in atopics. High Der p-specific IgE level and its ratio to serum free IgE level may be a potential biomarker for predicting favorable responses to omalizumab in CSU.

EAACI Biologicals Guidelines-Omalizumab for the treatment of chronic spontaneous urticaria in adults and in the paediatric population 12-17 years old

Chronic spontaneous urticaria (CSU) imposes a significant burden on patients, families and healthcare systems. Management is difficult, due to disease heterogeneity and insufficient efficacy of classical drugs such as H₁ R-antihistamines. Better understanding of the mechanisms has enabled a stratified approach to the management of CSU, supporting the use of targeted treatment with omalizumab. However, many practical issues including selection of responders, the definition of response, strategies to enhance the responder rate, the duration of treatment and its regimen (in the clinic or home-based) and its cost-effectiveness still require further clarification. The EAACI Guidelines on the use of omalizumab in CSU follow the GRADE approach in formulating recommendations for each outcome. In addition, future therapeutic approaches and perspectives as well as research priorities are discussed.

Efficacy of NB-UVB as Add-on Therapy to Antihistamine in the Treatment of Chronic Urticaria: A Systematic Review and Meta-analysis

Introduction

Narrow-band ultraviolet B (NB-UVB) phototherapy has been used for the treatment of chronic urticaria (CU), but the clinical efficacy of this treatment modality requires further evidence. A systematic review and meta-analysis of randomized clinical trials were conducted to evaluate the efficacy and safety of NB-UVB as add-on therapy in the treatment of CU.

Methods

A literature search was conducted in the Cochrane, Embase, PubMed, Web of Science, CNKI, CBM, VIP and WanFang databases up to October 2020. A total of nine studies involving 713 participants met the inclusion criteria.

Results

Two trials showed a significant difference in the Urticaria Activity Score between therapy with NB-UVB + antihistamines and that with antihistamines alone (mean difference 8.23, 95% confidence interval [CI] 5.78–10.68, p < 0.00001). Six trials (563 participants) showed a significant benefit of NB-UVB as add-on therapy to antihistamines in the total effective rate (risk ratio [RR] 1.56, 95% CI 1.39–1.75, p < 0.00001). In terms of adverse events, no statistically significant differences were found for NB-UVB + antihistamines versus antihistamines alone (RR 1.10, 95% CI 0.67–1.79, p = 0.71). Combination therapy of NB-UVB + antihistamines yielded a significantly lower risk of recurrence (RR 0.25, 95% CI 0.14–0.44, p < 0.00001).

Conclusion

Our meta-analysis suggests that combination therapy of NB-UVB + antihistamines is significantly more effective in treating CU than antihistamines alone.

Clustering the Clinical Course of Chronic Urticaria Using a Longitudinal Database: Effects on Urticaria Remission

Purpose

Little is known about the clinical course of chronic urticaria (CU) and predictors of its prognosis. We evaluated CU patient clusters based on medication scores during the initial 3 months of treatment in an attempt to investigate time to remission and relapse rates for CU and to identify predictors for CU remission.

Methods

In total, 4,552 patients (57.9% female; mean age of 38.6 years) with CU were included in this retrospective cohort study. The K-medoids algorithm was used for clustering CU patients. Kaplan-Meier survival analysis with Cox regression was applied to identify predictors of CU remission.

Results

Four distinct clusters were identified: patients with consistently low disease activity (cluster 1, n = 1,786), with medium-to-low disease activity (cluster 2, n = 1,031), with consistently medium disease activity (cluster 3, n = 1,332), or with consistently high disease activity (cluster 4, n = 403). Mean age, treatment duration, peripheral neutrophil counts, total immunoglobulin E, and complements levels were significantly higher for cluster 4 than the other 3 clusters. Median times to remission were also different among the 4 clusters (2.1 vs. 3.3 vs. 6.4 vs. 9.4 years, respectively, P < 0.001). Sensitization to house dust mites (HDMs; at least class 3) and female sex were identified as significant predictors of CU remission. Around 20% of patients who achieved CU remission experienced relapse.

Conclusions

In this study, we identified 4 CU patient clusters by analyzing medication scores during the first 3 months of treatment and found that sensitization to HDMs and female sex can affect CU prognosis. The use of immunomodulators was implicated in the risk for CU relapse.

Moxibustion therapy for chronic spontaneous urticaria: A protocol for systematic review and meta-analysis

BACKGROUND

Chronic spontaneous urticaria (CSU) is a common disease in clinical, and often recrudescent. However, sometimes Western medicine treatments such as antihistamines cannot completely control the symptoms of CSU; therefore, more effective and optimized treatments are needed. Numerous studies have confirmed that moxibustion therapy is effective in treating CSU. Given that no relevant systematic reviews and meta-analysis have been carried out, we set out to prove the effect of moxibustion therapy for CSU.

METHODS

This protocol will be conducted based on the PRISMA-P guidelines and comply with the recommendations of the Cochrane Collaboration Handbook for Systematic Reviews. We plan to search the subsequent databases: PubMed, Web of Science, EMBASE.com and Cochrane Library, China National Knowledge Infrastructure, WanFang Database, Chinese Science Journal Database, and China Biomedical Literature Database. The studies will be screened under the eligibility criterion. The quality of the studies will be assessed based on the Cochrane risk bias tool. Ultimately, Review Manager 5.3 will be used for statistical analysis.

RESULTS

This research will comprehensively evaluate the effectiveness of moxibustion therapy for CSU, and provide a more reasonable and effective treatment plan for CUS.

CONCLUSION

This research will bring new evidence for the efficacy of moxibustion therapy in the treatment of CSU and provide a basis for future clinical applications.

INPLASY REGISTRATION NUMBER

INPLASY2020100045.